Anthem Blue Cross Application
Instructions for Download

In order to print this application you will need to have Adobe Acrobat Reader in order to properly view and print the application.  If you do not have Adobe Acrobat Reader please visit www.adobe.com and you can download it from their site.

Please Note:
Coverage is not available if:

1. Any family member is currently pregnant (whether or not listed on the application) or in the process of adoption.
2. The applicant has not resided in the U.S. for the last six (3) consecutive months.
3. You are not a permanent legal resident of California

Coverage is not guaranteed.  Your application must be approved and accepted in writing by Anthem Blue Cross.  Do not cancel existing coverage until you receive written notification by Anthem Blue Cross.

Instructions

• For your own protection, you, the applicant, must complete the application.  You are solely responsible for its accuracy and completeness.
• If you, the applicant, do not complete the application, the translator must complete the "Statement of Accountability".
• All information must be stated accurately.
• All questions must be answered in full or the application may be returned to you and may result in a delay in processing.
• For additional information or explanations, attach sheets if necessary.  All attachments must be signed and dated.
• This application must be signed in blue or black ink.
• This application must be received by Anthem Blue Cross Medical Underwriting within 45 days from signature date.
• Anthem Blue Cross plans are available only in areas where the Anthem Blue Cross network exists.  Please see the appropriate provider directory for more details.
• Even if the application is approved, any misstatements or omissions may result in future claims being denied and the plan being voided from the beginning.
• Your insurance will become effective only if this application is approved as applied for, the appropriate premium is enclosed, and other specific conditions are met.
• Please return this application and your check to (Make Check payable to "Anthem Blue Cross") or complete the Credit Card Authorization section on the last page of the application.